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Commentary

Role of Nurses in Managing Chronic Disease

The Veterans Health Administration (VHA) serves a large population requiring care for chronic diseases such as diabetes mellitus, heart failure, hypertension, and chronic obstructive pulmonary disease. Moreover, many high risk Veterans with chronic disease have multiple comorbidities and psychosocial issues. These Veterans require care delivery designed to improve their quality of life and reduce overall costs of care. Additionally, the increased use of non-VA care necessitates robust care coordination efforts for Veterans with chronic disease. The role of the registered nurse (RN) has evolved to meet the increasingly complex care requirements of this Veteran population. Through their interventions, RNs contribute to improved outcomes and appropriate use of Veteran services. Nursing practice changes in outpatient and community settings have focused attention towards the value of RNs in improving outcomes and reducing the use of costly inpatient care.

RNs in VHA perform various roles across multiple settings to provide the necessary collaboration and coordination of services essential for patient-centered care delivery and optimal outcomes. RNs function as coordinators of care, providing significant value by reducing fragmentation and enhancing care transitions for the most complex patients. Since Veterans with chronic diseases often see specialty providers and may require different levels of care throughout their illness, RNs provide the support needed for Veterans and their families to navigate what can become a complex system of care. RNs conduct post-hospitalization phone calls to facilitate appropriate follow-up after acute care hospitalization. They also provide significant patient and family education, a critical component of successful chronic disease management. Utilizing their holistic approach, RNs further patient-centeredness to enhance care and satisfaction for the Veteran.

The VHA outpatient RN care manager role requires panel management of high-risk patients, chronic disease management, and facilitation of care transitions. The RN care manager coordinates care between services such as primary care, specialty care, behavioral health, and social work services. This coordination is particularly important for high-risk individuals to ensure smooth transitions and clear communication. RNs work as part of a team that may include physicians, nurse practitioners, pharmacists, and other healthcare professionals that support care delivery. They add capacity to the provider clinic by working at the full scope of their license and education, often using protocols to handle many things that would otherwise require provider time for this population of Veterans. RNs also provide direct patient care through independent nurse visits to conduct screenings and assessments, review lab tests, plan care and referrals, arrange home and community-based services, and teach Veterans and their caregivers. Non-face-to-face encounters may include secure messaging or telephone advice. For the individual with chronic illness, providing care when needed, while utilizing the most appropriate level of care improves quality and reduces costs of care.

Successful management of chronic conditions requires Veteran participation in their care and self-management skills. RNs assist Veterans to drive their care through setting patient-driven goals, ones that address real-life issues that matter to them. To promote self-management, the RN provides education on topics such as smoking cessation, medications, nutrition, exercise, and symptom management. Additionally, RNs provide coaching and support to facilitate decision-making and adoption of healthy behaviors. The RN uses specific interviewing techniques such as motivational interviewing to address uncertainties and assist the Veteran. The overall objective is to improve Veteran self-management to prevent exacerbation of their illness and reduce hospital readmissions and emergency department visits.

Advancing technology offers Veterans with chronic diseases alternative modalities for managing their disease. RNs play an important role in these new care modalities. One example is home telemonitoring, where nurses provide monitoring of disease symptoms, assessment of adherence to medication regimens, and monitoring of parameters such as body weight, blood pressure, and heart rate to detect early signs of illness exacerbation. Early identification and rapid response, often to subtle changes in a patient's condition, improves outcomes and may prevent higher cost services such as hospitalization. As alternative care modalities evolve in telehealth, continued research about the impact of services on patient satisfaction, access to care, hospital admissions, and emergency department visits is essential to guide nursing practice.

Nurse practitioners also play a critical role in managing Veterans with chronic disease. They enable VHA to provide accessible, cohesive, and coordinated care for Veterans with chronic disease. They serve as primary providers to help meet access requirements. While evidence demonstrates nurse practitioners deliver high quality, safe, and effective care with a holistic focus, more research is needed to determine system cost effectiveness and analysis of avoidable hospital admissions and Veteran satisfaction.¹

The Office of Nursing Services (ONS) continues to advance nursing practice to improve Veterans' care. An important aspect of improving care for Veterans with chronic disease includes building upon the RN role in management of Veterans requiring complex care. This effort will require development of each nurse's current knowledge about chronic disease management and increasing the use of evidence-based protocols and clinical practice guidelines.

Managing Veterans with chronic disease is highly complex and requires the use of evidence-based approaches. We have the responsibility to conduct research and determine best practice as we transform care delivery for Veterans. If we are to redesign future care delivery and implement innovative models of care, then evaluation of care delivery models and the role of the nurse is required to ensure quality and cost-effectiveness. References

References

1. Stanik-Hutt, et al. "The Quality and Effectiveness of Care Provided by Nurse Practitioners," The Journal for Nurse Practitioners 2013; 9(8):492-500.